Partner Survey

Evaluating Coverage to Care in Communities (CMS-10632)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1342 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10632 Partner Survey Form and Instruction
CMS-10632 Appendix A - Partner Survey: Informed Consent and Survey CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf Form and Instruction
CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf Recruitment script IC Document
CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf Letter of Support IC Document

Information Collection (IC) Details

IC Title:	Partner Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10632	Appendix A - Partner Survey: Informed Consent and Survey	CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Recruitment script	CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf	05/06/2021
Letter of Support	CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf	05/06/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.